Breast cancer screening recommendations have been a hot topic over the past year, as the US Preventive Services Task Force made changes to mammogram screening guidelines.  (1) The Centers for Disease Control and Prevention recommends that women 50-74 receive mammogram screenings at least every two years, and that women 40-49 decide with their doctors how often to be screened.  (2)  The American Cancer Society recommends women 20 -39 receive clinical breast exams at least every three years, while women 40 and older should have both clinical breast exams and mammograms each year (3). While opinions vary about whether annual screenings are required among all women, many adult women 18+ do receive annual clinical breast exams, and many women 40+ have a mammogram each year. 

In Southeastern Pennsylvania, women who face particular barriers to health care are less likely to have received these screenings.  A small, but notable percentage of women in our region have not been screened at all. 

Using data from the 2008 Southeastern Pennsylvania Household Health Survey, this article looks at who does and does not receive annual breast cancer screenings.  The Southeastern Pennsylvania Household Health Survey is a random digit dial telephone survey conducted every two years with 10,000 households in Bucks, Chester, Delaware, Montgomery, and Philadelphia Counties.

Breast Exam in the Past Year (Women 18+)

More than a quarter of women in SEPA (27.3%) have not had a clinical breast exam in the past year.  This represents approximately 427,700 women.
Latino women in Southeastern Pennsylvania are less likely to have had a clinical breast exam in the past year than other women in the region. 

Nearly two in five Latino women (38.1%) have not had a clinical breast exam in the past year, compared with 26.5% of White women, 25.0% of Black women and 23.4% of Asian women.

More than a third of women living below the Federal Poverty Line (35.9%) have not had a clinical breast exam in the past year, compared with about a quarter (26.0%) of women living above the Federal Poverty Line.

Women who report experiencing discrimination in obtaining medical care are more likely (38.7%) to have forgone a breast exam in the past year than women who have not experienced such discrimination (26.5%).

Women who report having been sick, but not seeking care due to the cost are more likely (44.0%) to have forgone a clinical breast exam in the past year than women who have not experienced these cost barriers to care (22.2%). 

Insurance status is a key factor in access to healthcare, including regular screenings (Figure 1). While a quarter (24.0%) of women ages 18-64 with health insurance have gone without a clinical breast exam in the past year, more than half of women ages 18-64 without health insurance (53.7%) have done the same.  Insurance type also plays a role in access to screenings.  Women enrolled in public health insurance plans are more likely to have not received a clinical breast exam in the past year compared to women with private insurance. Just over two in ten women with private health insurance (22.0%) have not had a clinical breast exam in the past year, compared with three in ten women with Medicaid (30.6%) or Medicare (31.8%), and 25.7% of women with other public insurance (Figure 2).

Never had a Clinical Breast Exam (Women 18+)

Approximately 46,800 women 18+ in Southeastern Pennsylvania (4.8%) have never had a clinical breast exam performed by a medical professional. 

Women in both younger and older age groups were more likely to report never having had a clinical breast exam: 8.9% of 18-39 year olds, 3.4% of 40-49 year olds, 1.8% of 50-59 year olds, 2.2% of 60-74 year olds and 5.4% of women 75 or older have never had a clinical breast exam.

Latino women in Southeastern Pennsylvania are more likely to have never received a clinical breast exam than other women in the region.  Nearly one in seven Latino women (15.4%) has never had a clinical breast exam, compared with 3.6% of White women, 5.6% of Black women and 6.7% of Asian women.

The likelihood of having never received a clinical breast exam decreases with education.  While nearly one in ten women who have completed less than high school (9.5%) have never had a clinical breast exam, 7.6% of high school graduates, 4.1% of women with some college, 2.3% of college graduates and 1.6% of women with post college education have not been screened.

Women living below the Federal Poverty Line (10.0%) are more than twice as likely to indicate they have never received a clinical breast exam than women with incomes at or above the Federal Poverty Line (4.1%).

Mammogram in the Past Year (Women 40+)

One third (33.7%) of women age 40 and older in Southeastern Pennsylvania have not had a mammogram in the past year, representing approximately 350,500 women.  This was fairly consistent across racial and ethnic groups: 33.8% of white women, 30.6% of black women, 35.0% of Latino women and 36.7% of Asian women 40+ have not had a mammogram in the past year.

Mammography in the past year is associated with education; as education level goes up, the likelihood of forgoing mammography goes down.  While more than two-fifths (41.8%) of SEPA women 40+ with less than a high school diploma have not had a mammogram in the past year, just over a third (35.4%) of high school graduates and those with some college (35.5%), have forgone the screening.  Slightly fewer college graduates (29.0%) and women with post college education (29.6%) report not having a mammogram in the past year.

Women 40+ who have experienced discrimination in receiving medical care are less likely to have had a mammogram in the past year (45.0%) than those who do not report experiencing such discrimination (32.7%). 

The cost of care appears to be a factor in women’s screening.  More than half of women 40+ (54.8%) who had felt that they needed care during the past year, but did not obtain it due to the cost also went without a mammogram in the past year, as compared to 31.1% of women who did not face these cost barriers. 

Women 40-64 without health insurance (66.0%) are more than twice as likely to go without a mammogram than those who are insured (31.0%) (Figure 1).  Among those with health insurance, insurance type may matter as well.  Just over a quarter (28.1%) of women 40+ with private insurance have not had a mammogram in the past year, while 35.8% of women 40+ covered by Medicare, 39.8% of women 40+ covered by Medicaid and 61.4% of women 40+ with another source of public insurance have not had a mammogram in the past year (Figure 2).  While about a third (32.8%) of women 40+ with a regular source of medical care have not had a mammogram in the past year, nearly half (46.5%) of women without a regular source of care have forgone screening.

Never had a Mammogram (Women 40+)

Approximately 35,400 women age 40 or older in Southeastern Pennsylvania, (6.3% of women in this age group) have never had a mammogram.
Again, education level appears to be a factor. 

While about one in ten women 40+ (9.7%) with less than a high school education never had a mammogram, 7.7% of women with a high school diploma, 6.1% of women with some college, 5.4% of college graduates and 3.3% of women with post college education never had a mammogram.

Women 40+ without health insurance are three times more likely (18.1%) to have never received a mammogram than those with health insurance (6.0%), and women without a regular source of health care are more likely (13.5%) to have never received a mammogram screening than women with a regular source of health care (5.8%).

Summary
Disparities in breast cancer screenings in Southeastern Pennsylvania appear by education, race/ethnicity, and several access to healthcare factors.  Women with limited access to medical care are less likely to receive annual screenings and more likely to have never received certain screenings than women with fewer barriers to care.  Several organizations in our area offer free or low cost breast cancer screening services. 

For more information about breast cancer screenings in Southeastern Pennsylvania, please contact Rose Malinowski Weingartner at rosemw@phmc.org or 215 985 2572.

For information on upcoming screening events, please visit CHDB affiliate Linda Creed at http://www.lindacreed.org/events.php.
(1) http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm
(2) http://www.cdc.gov/cancer/breast/basic_info/screening.htm
(3) http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer

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